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John Mandrola, MD

@drjohnm

Jun 19

@maahmed1218

I want to highlight a recent meta-analysis of the sham-controlled renal denervation trials #hypertension

From @maahmed1218 @AndrewFoy82 and others at Penn State.

Free access x 40 days here: sciencedirect.com/science/articl…

Comments >

They study the 10 sham-controlled trials of RDN. About 1500 patients.

Mean fu (and this is a limitation) = 4 months.

Primary outcomes of the meta-analysis: the *raw mean differences* in 24 hour ambulatory, daytime ambulatory, nighttime, and office SBP and DBP

Results are clear: RDN does indeed reduce BP.

They found statistically sig reductions in all categories accept nocturnal BP.

Here are the differences in 24 hour ambulatory SBP and office SBP.

Read 11 tweets

John Mandrola, MD

@drjohnm

Jul 18, 2021

https://twitter.com/JReinerMD/status/1416811058040344584

My colleague has an interesting idea on vax persuasion

But... Scott Alexander IDs a problem. All 4 folks he suggests are super smart & competent but they aren't optimized only for being correct, they are also optimized for keeping power.

See astralcodexten.substack.com/p/webmd-and-th…
1/

https://twitter.com/JReinerMD/status/1416811058040344584

I discussed my experience in clinic with vaccine hesitant patients on This Week in Cardiology podcast
podcasts.apple.com/us/podcast/jul…

Point 1: ... patients don't make decisions like odds-ratio-calculating robots. People feel risk.

Some feel more risk from the vaccine than COVID

Point 2: I don't think the average cardiac patient should feel that way and I do my best to persuade them that the clear benefit-harm choice is to get vaccinated.

Yet I make the same argument for anticoagulants, tobacco cessation etc and still many pts don't heed my advice.

Read 6 tweets

John Mandrola, MD

@drjohnm

May 16, 2021

When sacubitril/valsartan crushed it in 2014 in PARADIGM-HF for HFrEF, there were a few voices of criticism.

At #ACC21 the PARADISE-MI of entresto vs ramipril in post-MI patients w heart failure failed to show significance.

My summary
medscape.com/viewarticle/95…

Thread/

The specific message is obviously that based on this study, sac/val has no role over ACE/ARB in post-MI patients with heart failure and LV dysfunction.

We cannot ignore costs of care. And low BP was worse in the ARNI group.

The larger message--there is nearly always a larger message--is that we may have over-estimated this drug class.

It missed significance now in 2 of 3 outcome trials.
In PARAGON-HF of HFpEF and now PARADISE-MI.

Re PARADIGM, we know large effect sizes often don't replicate

Read 5 tweets

John Mandrola, MD

@drjohnm

Mar 13, 2021

@youyanggu

Pure gold in this convo on #covid19

Why has @youyanggu been so accurate modeling?

Go to 39-minute mark and replay his words 100x

“When the data do not fit what I expected, I change my beliefs”

If only this was allowed in COVID science!

Brief thread 👇

https://twitter.com/plenary_session/status/1370509641709359107

@youyanggu

This principles in this podcast are so darn important for critical appraisal

@youyanggu lack of prior infectious disease knowledge is a feature not a bug.

It allows a dispassionate interpretation of evidence.

Say it w me: **content expertise is over-rated!**

2/

I’m all about Bayes, but the novel-ness of COVID-19, and the fact that it’s a once-in-a-lifetime pandemic, should reduce (or eliminate) any prior beliefs.

I dare say the frequentist-like approach may have been better for Covid.

4/

Read 5 tweets

John Mandrola, MD

@drjohnm

Mar 12, 2021

@bostonsci

Excited to share our recently published point-counterpoint paper on halting implantation of the @bostonsci subcutaneous-ICD

The paper is now open access.

A brief thread

https://twitter.com/JACCJournals/status/1370457134194917381

Background:
I have used the S-ICD. It has *potential* advantages over the traditional trans-venous ICD system

But it is the newcomer. A #MedicalConservative believes proponents of new stuff must show more than *potential* benefits over the tried and true.

@bogdienache

Recent Issues w the S-ICD:

In the first part of the commentary @bogdienache and I focus our argument around:

-Two Class 1 FDA recalls of the S-ICD
-Serious concerns over the PRAETORIAN trial-- the only trial RCT comparing transvenous ICD (standard) to S-ICD

Read 11 tweets

John Mandrola, MD

@drjohnm

Jan 30, 2021

@PerPersvensson

Ok at the request of @PerPersvensson let's do a
Bayes Analysis of the HERS trial circa JAMA 1999

Estrogen/progesterone vs Placebo for reduction of MI/CV death.

https://twitter.com/PerPersvensson/status/1355426831797772290

Here are the events to put in the 2x2 table and the published CI and RR

First just look at the data. No diff in outcomes and wide CI from 20% benefit to 22% harm.

Going to be hard for prior beliefs to budge our posterior

Posterior is jargon for after seeing the data.

Goodman has a nice paper on using Bayes courses.botany.wisc.edu/botany_940/06E…

First step is to calculate a likelihood ratio. We do this in our heads all the time as doctors.

The LR is called the Bayes Factor and it is simply the ratio of the probability of the null H over the alternative H

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